GPs must fight against health inequities, conference hears

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For decades, the academics as well as public health managers have
shown to harbour a belief that the cultural determinants of health would
be suitably taken care of when we effectively address the broader domain
of social causations. This is placing the cart before the horse. Several
of the social determinants are merely proxy markers of deeper, and
probably causal, cultural determinants. Even the newly published report of
the Commission on Social Determinants of Health is short of expectations
on this score.1 We keep ourselves preoccupied with the issues of income,
education, occupation, social equity and access to health care while being
totally oblivious of the fact that some of the cleanest people of the
world are from some of the most deprived tribal areas, and several
communities in the world could achieve what they did, not because of their
per capita income but for their deeply rooted cultural strengths. On the
other hand, community based systematic resistance to supplementary
immunisation activities of polio eradication campaign that has been
witnessed in several pockets in India, Pakistan, Afghanistan and Nigeria
can not be totally explained as behaviour of economically disadvantaged
communities.2,3 We seem to be a little reluctant to identify a strong
component of cultural resistance in this, and sometimes the pressure of
political correctness smothers such enquiries. On another related front,
while we think that privatisation of health care would solve most of the
problems, nearly all of the female feticide in South Asia is being done
and abated by private sector – and some of the richest and best educated
people in this part of the world are involved in killing our daughters in
utero, either as client or as provider.4,5 Can this phenomenon be
deconstructed without understanding the cultural determinants that sustain
male child preference, cynically supported by dowry system in marriage?
And above all, can we possibly explain the constant marginalisation of
natives, aborigines and tribal people across the globe without analysing
the cultural attributes of the dominant occupants of the land?6-8 Time
has come for a dedicated identification of such determinants of health and
health care and their rational, sensitive and proactive management. It
demands a studied departure from our old habit of shying away from
cultural causations and covering them up with proxy, quasi-effective
social factors. To initiate, we may start with following sub-sets of the
wider ambit of cultural domain – and they do not need much evidence to be
elicited.

Cultural acceptability for substance abuse: Use and abuse of a wide
range of tobacco products and alcohol is goaded by the level of cultural
acceptability these products enjoy in the public space. In several
regions, there is virtually no resistance to chewable tobacco. Societal
acceptability for alcohol abuse is of pandemic proportions. People
visiting evening bars drive back on their own – drunk, putting themselves
and road users at grave risk. Many of them are opinion leaders and role
models for youth. In the developing countries, maternal and child health
pays a very heavy price for the habitual alcohol abuse by their men.9,10
Households gradually fall in a debt trap, men die earlier, children are
left to mothers and there is no one to care for the mothers. In several
regions, men’s alcoholism is perhaps the most important yet
underrepresented cause of chronic undernutrition among women and children.

Culture that tolerates or promotes violence: Gender violence;
violence against children, weak, poor and voiceless people; violence
amongst youth; and road rage are some of the phenomena that can not be
sustained unless supported by some well entrenched cultural factors. The
way several societies continue to associate violence with youth, adventure
and masculinity; events of domestic violence, and even rape are not found
worthy of reporting; and inexplicable mass violence is systematically
rationalised by many through ideological constructs is essentially
cultural and needs to be examined in that light.11-14

Culture influenced by visible and invisible markets: An overwhelming
number of competing actors are using marketing and advertising to mould
and monitor the meanings which people derive for anything from product to
policy. When solely driven by profit, this can initiate a huge process of
mass disempowerment and misinformed decision making. Mass media,
understandably, will not seriously question the values of the economic
interests from which they derive sustenance. Popular media ends up
promoting higher levels of consumption of a range of health compromising
products and ideas through attractive role models and life style appeals.
Advertising covers a large part of public space while health messages last
for few seconds. A relentless mass counselling, by hidden and not so
hidden persuaders, is chiefly visible in: unhealthy food culture;
unhealthy beauty-culture that is inherently Eurocentric and subtly racist
in its construct; excessive portrayal of gender identity and sexuality;
risky behaviours, especially amongst youth; substance abuse; easily
avoidable filth and noise generating behaviours.15-19

The science of social determinants is ill equipped to deal with a
much more complex web of these cultural causations. We may need a
dedicated space to examine and intervene in this rather amorphous area of
what we may call as – cultural epidemiology. Sooner the better.

********

References

1. World Health Organisation, Commission on Social Determinants of
Health. Closing the gap in a generation: health equity through action on
the social determinants of health. Final report of the Commission on
Social Determinants of Health. Geneva: The Organization; 2008.

It is extremely promising to read that GPs are being encouraged to
address health inequalities – an area until now almost solely the concern
of public health. Identified by the Department of Health as a top
priority, the reduction of health inequalities is often overlooked by
clinical staff within the NHS.

While GPs may be limited in what they can do individually, the Royal
College of General Practitioners is in a strong position to influence
policy towards addressing inequities in relation to health.

Doran may be right in stating that the QOF “was not designed to
reduce health inequalities”. There is, however, evidence of GP practices
in the most deprived areas achieving greater increases in QOF indicators
when compared to their counterparts in more affluent areas.1 While such an
association does not necessarily imply causality, and improved QOF
performance does not necessarily imply better population health, the
possibility of reducing health inequalities is a welcome side-effect of
this financial incentive scheme.

But in order to successfully reduce health inequalities, we cannot
afford to rely on initiatives with serendipitous benefits for the
deprived. Instead, we need cross-disciplinary commitment and organised
efforts to place the reduction of health inequalities at the centre of all
health policies. Only then might we begin to see an end to the
persistently widening gap in health outcomes.2